5160-58-02.1
MyCare Ohio plans: termination of enrollment.

(A)
A member will be terminated from
enrollment in a MyCare Ohio plan ("plan") for any of the following reasons:

(1)
The member becomes ineligible for full
medicaid or medicare parts A or B or D. Termination of plan enrollment is
effective the end of the last day of the month in which the member became
ineligible.

(2)
The member's
permanent place of residence is moved outside the plan's service area.
Termination of plan enrollment is effective the end of the last day of the
month in which the member moved from the service area.

(3)
The member dies, in which case
plan enrollment ends on the
date of death.

(4)
The member is
found by the Ohio department of medicaid (ODM), or their designee, to meet the criteria for
the
developmental disabilities (DD) level of care and
has a
stay in an intermediate care facility for
individuals with intellectual disabilities (ICF-IID) or
is enrolled in a DD waiver. After the
plan notifies ODM this has occurred,
termination of plan enrollment takes effect on the last day of the month
preceding the ICF-IID facility
stay or enrollment on the
DD
waiver.

(5)
The member has third
party coverage, excepting medicare coverage, and ODM determines
it is not in the best interest of the
member to continue in the plan. The effective date of termination shall be
determined by ODM but in no event shall the termination date be later than the
last day of the month in which ODM approves the termination.

(6)
The provider agreement between ODM and
the plan is terminated or not renewed. The effective date of termination shall
be the last day of the month of the provider agreement termination or
nonrenewal.

(7)
The member is not
eligible for enrollment in a plan for one of the reasons set forth in rule
5160-58-02
of the Administrative Code.

(B)
All of the following apply when
enrollment in a MyCare Ohio plan is terminated for any of the reasons set forth
in paragraph (A) of this rule:

(1)
Such
terminations may occur either in a mandatory or voluntary service
area;

(2)
All such terminations
occur at the individual level;

(3)
Such terminations do not require completion of a consumer contact record
(CCR);

(4)
If
ODM fails to notify the plan of a member's termination from the plan, ODM shall
continue to pay the plan the applicable monthly premium rate for the member.
The plan shall remain liable for the provision of covered services as set forth
in rule
5160-58-03
of the Administrative Code, until ODM provides the plan with documentation of the member's
termination.; and

(5)
ODM shall recover from the plan any
premium paid for retroactive enrollment termination occurring as a result of
paragraph (A) of this rule.

(C)
Member-initiated terminations.

(1)
A dual-benefits
member may request disenrollment from the plan and transfer between plans on a
month-to-month basis any time during the year. Plan coverage continues until
the end of the month of disenrollment.

(2)
A medicaid-only member may request a
different plan in a mandatory service area as
follows:

(a)
From the date of initial
enrollment through the first three months of plan enrollment, whether the first
three months of enrollment are dual-benefits or medicaid-only enrollment
periods;

(b)
During an open
enrollment month for the member's service area as described in paragraph (E) of
this rule; or

(c)
At any time, if
the just cause request meets one of the reasons for just cause as specified in
paragraph (C)(4)(e) of this rule.

(3)
A medicaid-only member may request a
different plan if available or be returned to medicaid fee-for-service in a
voluntary service area as follows:

(a)
From
the date of enrollment through the initial three months of plan
enrollment;

(b)
During an open
enrollment month for the member's service area as described in paragraph (E) of
this rule; or

(c)
At any time, if
the just cause request meets one of the reasons for just cause as specified in
paragraph (C)(4)(e) of this rule.

(4)
The following provisions apply when a
member either requests a different plan in a mandatory service area, requests
disenrollment in a voluntary service area, or qualifies as voluntary population
as set forth in rule
5160-58-02
of the Administrative Code:

(a)
The request
may be made by the member, or by the member's authorized
representative.

(b)
All
member-initiated changes or terminations must be voluntary. Plans are not
permitted to encourage members to change or terminate enrollment due to a
member's race, color, religion, gender, gender
identity, sexual orientation, age, disability, national origin, veteran's
status, military status, genetic information, ancestry, ethnicity, mental
ability, behavior, mental or physical disability, use of services, claims
experience, appeals, medical history, evidence of insurability, geographic
location within the service area, health status or need for health services.
Plans may not use a policy or practice that has the effect of discrimination on
the basis of the above criteria.

(c)
If a member requests disenrollment
because he or she meets any of the requirements
in rule
5160-58-02
of the Administrative Code, the member will be disenrolled after the member
notifies the consumer hotline.

(d)
Disenrollment will take effect on the last day of the calendar month as
specified by an ODM-produced HIPAA compliant 834 daily or monthly file sent to
the plan.

(e)
In accordance with
42 C.F.R. 438.56 (October 1, 2017), a change
or termination of plan enrollment may be permitted for any of the following
just cause reasons:

(i)
The member moves out
of the plan's service area and a non-emergency service must be provided out of
the service area before the effective date of a termination that occurs for one
of the reasons set forth in paragraph (A) of this rule;

(ii)
The plan does not, for moral or
religious objections, cover the service the member seeks;

(iii)
The member needs related services to be
performed at the same time in a coordinated manner; however, not all related
services are available within the plan network, and the member's primary care
provider (PCP) or another provider determines that receiving services
separately would subject the member to unnecessary risk;

(iv)
The member has experienced poor quality
of care and the services are not available from another provider within the
plan's network;

(v)
The member receiving long-term services and supports
would have to change their residential, institutional, or employment supports
provider based on that provider's change in status from an in-network to and
out-of-network provider with the plan and, as a result, would experience a
disruption in their residence or employment;

(vi)
The member cannot
access medically necessary medicaid-covered services or cannot access the type
of providers experienced in dealing with the member's health care
needs;

(vii)
ODM determines that continued enrollment in the
plan would be harmful to the interests of the member.

(f)
The following provisions apply when a
member seeks a change or termination in plan enrollment for just cause:

(i)
The member or an authorized
representative must contact the plan to identify providers of services before
seeking a determination of just cause from ODM.

(ii)
The member may make the request for just
cause directly to ODM or an ODM-approved entity, either orally or in
writing.

(iii)
ODM shall review all
requests for just cause within seven working days of receipt. ODM may request
documentation as necessary from both the member and the plan. ODM shall make a
decision within ten working days of receipt of all necessary documentation, or
forty-five days from the date ODM receives the just cause request. If ODM fails
to make the determination within this timeframe, the just cause request is
considered approved.

(v)
Regardless of the procedures followed,
the effective date of an approved just cause request must be no later than the
first day of the second month following the month in which the member requests
change or termination.

(vi)
If the
just cause request is not approved, ODM shall notify the member or the
authorized representative of the member's right to a state hearing.

(vii)
Requests for just cause may be
processed at the individual level or case level as ODM determines necessary and
appropriate.

(viii)
If a member
submits a request to change or terminate enrollment for just cause, and the
member loses medicaid eligibility prior to action by ODM on the request, ODM
shall assure that the member's plan enrollment is not automatically renewed if
eligibility for medicaid is reauthorized.

(D)
The following provisions apply
when a termination in plan enrollment is initiated by a plan for a
medicaid-only member:

(1)
A plan may submit a
request to ODM for the termination of a member for the following reasons:

(a)
Fraudulent behavior by the member;
or

(b)
Uncooperative or disruptive
behavior by the member or someone acting on the member's behalf to the extent
that such behavior seriously impairs the plan's ability to provide services to
either the member or other plan members.

(3)
The plan must provide
covered services to a terminated member through the last day of the month in
which the plan enrollment is terminated.

(4)
If ODM approves the plan's request for
termination, ODM shall notify in writing the member, the authorized
representative, the medicaid consumer hotline and the plan.

(E)
Open enrollment

Open enrollment months will occur at least annually. At least
sixty days prior to the designated open enrollment month, ODM will notify
eligible individuals by mail of the opportunity to change or terminate
enrollment in a plan and will explain how the individual can obtain further
information.